First-Day Attestation: Barbara Watkins, R.N.

How many patients are in your total portfolio?In terms of active patients, we have somewhere between 15,000 and 20,000.Though you certainly facilitated attestation at every level, don’t physicians technically have to attest individually?Yes, we attested them all individually. Each physician registers uniquely him- or herself, and then you go in and attest for each, so you have to run reports for each doctor. I did it on the 18th and finished on the 19th. Part of the problem is that you’re constantly running reports to make sure you’re ready.It’s a little different for a small group. We’re really very, very dependent on our vendor. Really, GE has pulled out the stops on the meaningful use reports; it’s a whole new bailiwick of reports we need to run to prepare for this meaningful use attestation.What have been the challenges, and has anything been easier than you thought?Well, I’m very proud of the physicians and of how they practice. I’m a nurse myself. And when I ran the first pass of the reports, I was really pleased, because they were meeting some of the goals without a blink of an eye, some of the requirements around things like CPOE [computerized physician order entry] for medication orders, and documenting drug-to-drug and drug-allergy interactions, e-prescribing, allergies, demographics, those demographic requirements. That was a kind of big hurdle. Ethnicity wasn’t something we normally had collected; we had collected race. But now, CMS [the federal Centers for Medicare and Medicaid Services] is not only looking at race, but also ethnicity. And vital signs are another area to cover; those are all examples of core measures.And when I ran those reports—even smoking status, you want everyone to ask that question and to document—but are they really doing it? And they were! So I was very, very pleased. And when we reviewed the criteria in the fall for meaningful use and then actually got into the nitty-gritty of it, we analyzed all of the requirements together. And some things we’re already doing—we already have a patient portal, and are already exchanging data with patients in real time. But I’m not really getting credit for any of that in CMS’s eyes; because the patient has to request an electronic copy of their health information, whereas in fact, I’m already proactively providing it.When did you begin the really active preparation?During the fall, when they came out with the final rule, we began our planning; and then towards December, we started actively honing in on how we were doing things; and workflows were exceptionally important. You actually need to sit down with the physicians while they’re using the EMR. The EMR is a very powerful tool; and Centricity is an amazing product. And part of it is making sure the “obs” [observation] terms—that we were using the right ones, because the reports can pick up one term, while we might be using a different one. So that’s really an important exchange of information between our office and Centricity. For example, we take and record a patient’s blood pressure on both arms at every visit. And we use a very specific kind of terminology to describe it, and the people at GE need to make sure that what we’re using is being picked up in Centricity; otherwise, it will look like we never do it. That actually happened on some reports. So moving forward on all this requires major partnership with your vendor. In fact, I would say that vendor support is especially important for physician practices. I mean, hospitals have their own issues, but they also have whole IT departments. Here, it’s basically me, a nurse practitioner, and a back-office support person making sure we’re meeting all the requirements.What have your biggest learnings been so far in all of this?That we had to modify our practice to be able to report on some of these measures. Here’s an example. Medication reconciliation is done in our practice at every single office visit, because we’re specialists. When the patient comes in for a visit, the patient could most recently have visited any other type of specialist; so we’re constantly doing medication reconciliation with our patients. But CMS is looking at med rec in the context of the concept of transition of care, so if it’s a post-op visit, they’re viewing that as a transition of care. So we have to document that we’re doing med rec as a transition of care. That means that we have to put a data point somewhere in the patient’s visit that tracks that visit as a transition of care, even though we know that it already is. So in the real world, we have to modify our behaviors so that we can report on these items, in order to document it for CMS.What would your advice be for your peers in other medical groups?To really start with your workflows: figure out how the [data-reporting] measures apply to your practice, and then really match the reporting requirements to your workflows. You have to study that very carefully; and that takes some time. They’ve got 15 core measures here. I was very surprised that they started out this aggressively, because you really have to take some time and go through it, and then there are your quality measures as well.How do you best engage the physicians to collaborate well in this whole process?We started out by running the reports, and then the physicians saw some successes, and saw some deficiencies. So showing them the data right away is key. And there is that element of physician-physician competition. You end up with situations where one doctor says, ‘Wow, you had 83 percent for showing patients educational information, and I only had 65 percent, so I’d better get on the stick.’ It’s that kind of thing that can motivate them on an individually level. Similarly with regard to e-prescribing, some of the doctors were already there, while others had to be cajoled a bit; so basically, showing the data is very important.Are you pretty optimistic about stages 2 and 3?I’m more optimistic about stage 2. I think the exchange of data between providers not related to one another concerns me a little bit. I know the Phoenix market really well, and I don’t see that exchange of data taking place here on a major scale yet. I’m looking at those very carefully obviously, because we want to be able to meet that goal. But I actually only have one or two doctors who’ve signed up for our physician portal. I mean, I think CMS’s goals are bold, and there are a number of organizations that will be able to respond to its goals, but there are an awful lot of people out there who are going to need a lot of help.Do you have anything else you’d like to add?Just that I’m really excited about all our little octogenarians going onto our patient portal. And I’ve got a 92-year-old patient on our portal all the time. Our patients are very engaged!